How Medicare Part A & B Claims Are Processed

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Topics on this page:

  1. Overview
  2. If You Have a Medigap (Supplemental Insurance) Policy or Retiree Plan
  3. Calling About Claims

Note: This section focuses on claims for original, fee-for-service Medicare. Claims for Medicare Part C – Medicare Advantage plans (including Medicare Health Maintenance Organizations – HMOs) and Medicare Part D – prescription drug plans are processed differently.

Overview

Your Medicare Part A and B claims are submitted directly to Medicare by your providers (doctors, hospitals, labs, suppliers, etc.). Medicare takes approximately 30 days to process each claim.

Medicare pays Part A claims (inpatient hospital care, inpatient skilled nursing facility care, skilled home health care and hospice care) directly to the facility or agency that provides the care. You are responsible for deductibles , copayments and non-covered services.

Medicare pays Part B claims (doctors' services, outpatient hospital care, outpatient physical and speech therapy, certain home health care, ambulance services, medical supplies and equipment) either to your provider or you. This is determined by assignment :

  • If the provider accepts assignment (agrees to accept Medicare's approved amount as full reimbursement), Medicare pays the Part B claim directly to him/her for 80% of the approved amount. You are responsible for the remaining 20% (this is your coinsurance ).
  • If the provider does not accept assignment, he/she is required to submit your claim to Medicare, which then pays the Part B claim directly to you. You are responsible for paying the provider the full Medicare-approved amount, plus an excess charge . Note: A provider who treats Medicare patients but does not accept assignment cannot charge more than 115% of the Medicare-approved amount. For more information, see Assignment for Original Fee-for-Service Medicare .

Medicare will send you a Medicare Summary Notice (MSN) form each quarter.

For Medicare Part A claims,
the MSN will state:

  • The date of service
  • The number of benefit days used (in a benefit period )
  • Any non-covered charges that apply
  • Any applicable deductibles or coinsurance
  • How much you owe

For Medicare Part B claims,
the MSN will state:

  • The date of service
  • Service(s) provided
  • The amount each provider charged
  • Whether the claim(s) were assigned
  • How much Medicare approved and paid
  • How much you owe

Previously known as the Explanation of Medicare Benefits, the MSN is not a bill. You should not send money to Medicare after receiving an MSN. Your provider will bill you separately.

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If You Have a Medigap (Supplemental Insurance) Policy or Retiree Plan

Your Medigap (supplemental insurance) company or retiree plan receives claims for your services 1 of 3 ways:

  1. Directly from Medicare through electronic claims processing. This is done online.
  2. Directly from your provider, if he/she accepts Medicare assignment. This is done online, by fax or through the mail.
  3. From you. If neither Medicare nor the provider submits the claim, you will need to file the claim yourself. Follow these steps:
    • Fill out the claim form provided by your insurance company (if required).
    • Attach copies of the bills you are submitting for payment (if required).
    • Attach copies of the MSN related to those bills.
    • Make copies of everything for your personal records.
    • Mail your claim packet to the Medigap company or retiree plan.

Note: You may need to pay a provider bill before you get your quarterly MSN. In this case, check your MSN when you receive it to see if you overpaid. If so, call your provider to request a refund. If you have any questions about the bill, call your provider. You can also contact your local Health Insurance Counseling & Advocacy Program (HICAP) office online or at 1-800-434-0222.

You will also receive an Explanation of Benefits (EOB) from your Medigap company or retiree plan. The EOB will show you how much was paid. If you don't receive an EOB within 30 days of the service date, call your plan to ask about the status of your claim.

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Calling About Claims

Follow these pointers when you call to discuss your claims.

Calling Medicare, Your Medigap Company or Retiree Plan

  • Identify yourself. Provide your Medicare number, insurance policy number or the account number from your latest bill.
  • Identify your claim: the type of service, date of service and bill amount.
  • Ask when your claim will be processed and when you will find out how much has been paid by Medicare or your Medigap company or retiree plan.

Calling Your Health Care Provider

  • Identify yourself. Provide your Medicare number, insurance policy number or the account number from your latest bill.
  • Identify your claim: the type of service, date of service and bill amount.
  • Ask if the provider accepted assignment for the service.
  • Ask how much is still owed and, if necessary, discuss a payment plan.

Be sure to take notes, including the date and time of your call, the name of the person you spoke to, and the topics you discussed.

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Updated April 24, 2009

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